REQUEST BY VICTIM OF SEXUAL ACT TO TEST DEFENDANT FOR AIDS/HIV STATE OF CONNECTICUT SUPERIOR COURT www.jud.ct.gov JD-CR-105 Rev. 10-06 C.G.S. §§ 19a-581 to 19a-585, 54-102a, 54-102b INSTRUCTIONS TO VICTIM: Forward completed original and three copies to the clerk of court. Retain a copy for your records. INSTRUCTIONS TO CLERK: Pursuant to C.G.S. § 54-86e, the name and address of the victims of sexual assaults, or attempts, are confidential and only disclosable on order of the court, except it is available to the accused. Place in a sealed envelope and maintain with the court file. Send one copy to the State's Attorney and one copy to the defendant's attorney. TO: The Superior Court of the State of Connecticut JUDICIAL DISTRICT OR G.A. NO. ADDRESS OF COURT (No., street, town and zip code) NAME OF DEFENDANT CRIME(S) CHARGED AGAINST DEFENDANT NAME OF VICTIM DOCKET NO. ADDRESS TO WHICH NOTICE TO VICTIM IS TO BE SENT REQUEST THAT THE DEFENDANT BE TESTED FOR AIDS/HIV I, the undersigned victim, hereby make the following statements and request: 1. The above-named defendant is accused of a violation of section 53a-70 (sexual assault, 1st degree), 53a-70a (aggravated sexual assault, 1st degree), 53a-70b (sexual assault in a spousal or cohabiting relationship) or 53a-71 (sexual assault, 2nd degree) of the general statutes or a violation of section 53-21 (injury or risk of injury to a child), 53a-72a (sexual assault, 3rd degree), 53a-72b (sexual assault, 3rd degree with a firearm), or 53a-73a (sexual assault, 4th degree) of the general statutes involving a sexual act, as that term is defined in general statutes section 54-102b. 2. I am the victim of such crime. 3. I hereby request that above-named defendant be tested: ("X" one or both) AS SOON AS POSSIBLE UPON THE COURT ENTERING A JUDGMENT OF CONVICTION for the presence of the etiologic agent for acquired immune deficiency syndrome (AIDS) or human immunodeficiency virus (HIV) and that the results be disclosed to me. I have read the above and understand it. I agree to the foregoing statements. SIGNED (Victim/Consented to by Parent or Guardian of minor Victim/Attorney for Victim) DATE SIGNED ORDER OF THE COURT It is hereby ORDERED by the court: Request DENIED. Request GRANTED. (C.G.S. § 54-102b requires granting request if the defendant is convicted or adjudicated delinquent.) If the defendant is incarcerated, convicted or adjudicated delinquent, the Commissioner of Correction is hereby ordered to have the above-named defendant tested for the presence of the etiologic agent for acquired immune deficiency syndrome or human immunodeficiency virus. Said test shall be performed by or at the direction of the Department of Correction in consultation with the Department of Public Health. The provisions of sections 19a-581 to 19a-585, inclusive, and section 19a-590 of the general statutes, except the requirement that the subject of an HIV-related test provide informed consent prior to the performance of such test and except any provision that would prohibit or limit disclosure of the results of such test to the victim, the court or the Department of Public Health if so ordered below, shall apply to the test ordered and the disclosure of the results of such test. If the defendant is not incarcerated, convicted or adjudicated delinquent, the defendant shall forthwith select a Department of Public Health testing site from a list provided by the clerk of the court and the testing site is hereby ordered to have the above-named defendant tested for the presence of the etiologic agent for acquired immune deficiency syndrome or human immunodeficiency virus. The provisions of sections 19a-581 to 19a-585, inclusive, and section 19a-590 of the general statutes, except the requirement that the subject of an HIV-related test provide informed consent prior to the performance of such test and except any provision that would prohibit or limit disclosure of the results of such test to the victim, the court or the Department of Public Health if so ordered below, shall apply to the test ordered and the disclosure of the results of such test. The results of such test SHALL SHALL NOT be disclosed to the victim. (C.G.S. § 54-102b requires disclosure of results to the victim if the defendant was convicted or adjudicated delinquent. C.G.S. § 54-102a makes disclosure discretionary with the court if the defendant is accused but not convicted or adjudicated delinquent.) A report of the results of such test shall be filed with the Department of Public Health, on a form supplied by it, and filed with this court. ("X" only if the defendant is accused but not convicted or adjudicated delinquent.) BY ORDER OF THE COURT (Print or type name of judge) SIGNED (Judge) DATE SIGNED American LegalNet, Inc. www.FormsWorkflow.com